STATE OF CALIFORNIA
DEPARTMENT OF SOCIAL WELFARE
I DATE
9/3/68
NOTICE OF ACTION
MEDICAL ASSISTANCE
COUNTY OF LOS ANGELES / DEPARTMENT OF PUBLIC SOCIAL SERVICES
pSTATE NUMBER
1913-0505241
DEAR:
[ so
SOC. SEC. NO.
Marie Hyun
461S Fountain Avenue
Los Angeles, California 90029
P
RETURN ADDRESS AND TELEPHONE NUMBER
METRO. NORTH DISTRICT
MARIPOSA SUB OFFICE
50£6 SANTA MONICA BLVD.
LOS ANGELES, CALIF. 90029
PHONE: 666-4666
YOUR Q APPLICATION
H CERTIFICATION FOR MEDICAL ASSISTANCE [MEDI-CAL) HAS BEEN.
EFFECTIVE 9/1/68
(DATE)
EXPLANATION:
decreased
(TYPE OF ACTION)
Due to the change in your personal and incidental needs.
SINCERELY,
T. Liddell/File 1055/lcf
(NAME AND TITLE)
TYPE OF COVERAGE
Q GROUP I YOU ARE ELIGIBLE FOR ALL ALLOWABLE MEDICAL CARE SERVICES UNDER THE MEDICAL ASSISTANCE PROGRAM.
D GROUP II
YOU ARE ELIGIBLE FOR ALL ALLOWABLE MEDICAL CARE SERVICES WHILE A PATIENT IN A MEDICAL FACILITY,
BUT FOR ONLY LIMITED OUTPATIENT BENEFITS.
II COMPUTATION - SHARE OF MEDICAL COSTS
IF YOU HAVE INCOME AND/OR PROPERTY RESERVE IN EXCESS OF THE EXEMPTION ALLOWED UNDER
THE PROGRAM, YOU WILL BE RESPONSIBLE FOR PART OF THE COST OF MEDICAL CARE BEFORE THE
MEDI-CAL PROGRAM WILL PAY FOR ALLOWABLE SERVICES.
YOUR SHARE OF THE COST IS $ 4 Monthly FOR THE PERjQp9/l/68 ongoing AS DETERMINED BELOW:
A. YOUR INCOME
B. REAI & PERSONAL "HOP. RESERVE
C. COMPUTATION OF SHARE OF COST
SOURCE
AMOUNT
SOURCE
AMOUNT
INCOME FROM A.
$
$
$
PROPERTY RESERVE
FROM B.
$
$
$
$
$
TOTAL
$
TOTAL (net)
$
TOTAL
$
LESS ALLOWABLE
MAINTENANCE
$
EXEMPTION
$
EXCESS (too
$
YOUR SHARE
$
YOU MUST TELEPHONE OR WRITE TO US TO REPORT ANY CHANGE IN INCOME OR PROPERTY RESERVES, CHANGE
OF ADDRESS, ADMISSION TO, OR DISCHARGE FROM, HOSPITAL OR NURSING HOME.
76N584C—PA 5239 (REV. 12-67) - Cdb 2-68

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STATE OF CALIFORNIA
DEPARTMENT OF SOCIAL WELFARE
I DATE
9/3/68
NOTICE OF ACTION
MEDICAL ASSISTANCE
COUNTY OF LOS ANGELES / DEPARTMENT OF PUBLIC SOCIAL SERVICES
pSTATE NUMBER
1913-0505241
DEAR:
[ so
SOC. SEC. NO.
Marie Hyun
461S Fountain Avenue
Los Angeles, California 90029
P
RETURN ADDRESS AND TELEPHONE NUMBER
METRO. NORTH DISTRICT
MARIPOSA SUB OFFICE
50£6 SANTA MONICA BLVD.
LOS ANGELES, CALIF. 90029
PHONE: 666-4666
YOUR Q APPLICATION
H CERTIFICATION FOR MEDICAL ASSISTANCE [MEDI-CAL) HAS BEEN.
EFFECTIVE 9/1/68
(DATE)
EXPLANATION:
decreased
(TYPE OF ACTION)
Due to the change in your personal and incidental needs.
SINCERELY,
T. Liddell/File 1055/lcf
(NAME AND TITLE)
TYPE OF COVERAGE
Q GROUP I YOU ARE ELIGIBLE FOR ALL ALLOWABLE MEDICAL CARE SERVICES UNDER THE MEDICAL ASSISTANCE PROGRAM.
D GROUP II
YOU ARE ELIGIBLE FOR ALL ALLOWABLE MEDICAL CARE SERVICES WHILE A PATIENT IN A MEDICAL FACILITY,
BUT FOR ONLY LIMITED OUTPATIENT BENEFITS.
II COMPUTATION - SHARE OF MEDICAL COSTS
IF YOU HAVE INCOME AND/OR PROPERTY RESERVE IN EXCESS OF THE EXEMPTION ALLOWED UNDER
THE PROGRAM, YOU WILL BE RESPONSIBLE FOR PART OF THE COST OF MEDICAL CARE BEFORE THE
MEDI-CAL PROGRAM WILL PAY FOR ALLOWABLE SERVICES.
YOUR SHARE OF THE COST IS $ 4 Monthly FOR THE PERjQp9/l/68 ongoing AS DETERMINED BELOW:
A. YOUR INCOME
B. REAI & PERSONAL "HOP. RESERVE
C. COMPUTATION OF SHARE OF COST
SOURCE
AMOUNT
SOURCE
AMOUNT
INCOME FROM A.
$
$
$
PROPERTY RESERVE
FROM B.
$
$
$
$
$
TOTAL
$
TOTAL (net)
$
TOTAL
$
LESS ALLOWABLE
MAINTENANCE
$
EXEMPTION
$
EXCESS (too
$
YOUR SHARE
$
YOU MUST TELEPHONE OR WRITE TO US TO REPORT ANY CHANGE IN INCOME OR PROPERTY RESERVES, CHANGE
OF ADDRESS, ADMISSION TO, OR DISCHARGE FROM, HOSPITAL OR NURSING HOME.
76N584C—PA 5239 (REV. 12-67) - Cdb 2-68